COMPLIANCE INFO_2022 - Laserfiche WebLink

Home Browse Search

Please print or type. Form Approved OMB No 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2 Page1 of 3 Emergency Response Phone 4.Manifest Tracking Number JJ K WASTE MANIFEST 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing addressi Generator's Phone US EPA ID Number 6 Transporter 1 Company Name 7 Transporter 2 Company Name US EPA ID Number 8 Designated Facility Name and Site Address US EPA ID Number &VWI AWR4, IF* I AS7 Facility's Phone ga 91b.U.S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11 Total 12 Unit 13 Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt NolQf . 1 i Q Z +�1 W "- (7 4 14,Special Handling Instructions and Additional Information t !'KOF►i F* I/jai"W ZLI, A-SPHALl Lhb sal LX(ji i i 1 ,:-W R(+NCY CONTACT VK TORIA 15 GENERATOR'SIOFFEF,OR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified packaged. marked and labeledipla(arded.and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offeror's PnntedlTyped Name Signature Month Day Year J 16 International Shipments Im rt to U.S. ❑Export from U.S Port of entry/exit F- ? Transporter signature(for exports only) Date leaving U.S [X 17,Transporter Acknowledgment of Receipt of Materials Transporfer 1 PrintedTyped Name Signature Month Day Year IXO a Month Day Year Z Transporter 2 PnntedTTyTd Name Signature Q 18 Discrepancy 18a Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejector Manifest Reference Number. U.S.EPA ID Number r 181b Alternate Facility(a Generator) J U taa. Facility's Phone. Month Day Year Lo 18a Signature of Alternate Facility(or Generator) a Z otice: State O '9 Hazardous Waste Report Management Method Codes p.e.,codes for hazardous waste treatment,disposal,and recycling systems) Of California re 3 generator t0 IIOtOCO pUlreS 0 1 2. Photocopy and mail to DTSC with 30 days: 20 Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a P.0 BOX 400 Printed/Typed Name Signature I Sacramento, CA 95812-0400 GENERATOR'S INITIAL GUr f EPA Form 8700-22(Rev.12-17) Previous editions are obsolete.